Provider Demographics
NPI:1316100282
Name:WALLICK, JOSEPH ANTHONY (LVN MPH)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:ANTHONY
Last Name:WALLICK
Suffix:
Gender:M
Credentials:LVN MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 507
Mailing Address - Street 2:
Mailing Address - City:MORRO BAY
Mailing Address - State:CA
Mailing Address - Zip Code:93443-0507
Mailing Address - Country:US
Mailing Address - Phone:805-772-5181
Mailing Address - Fax:
Practice Address - Street 1:2178 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4535
Practice Address - Country:US
Practice Address - Phone:805-781-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 82442164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse